Closing the Obesity Diagnosis Gap: A New EHR-Based Measure Could Improve Population Health Outcomes

A new obesity measure championed by authors of a recent Journal of Clinical Endocrinology & Metabolism paper could move the needle in managing obesity in patients, aligning better with public health priorities and improving patient care overall by integrating obesity recognition into routine clinical practice across specialties.

Despite growing awareness of obesity as a chronic disease, many patients who meet body mass index (BMI) criteria still go undiagnosed in clinical practice. A new article in The Journal of Clinical Endocrinology & Metabolism introduces a validated process measure designed to flag patients who meet body mass index BMI criteria for obesity who are not formally diagnosed in the electronic health records (EHR).

This effort was a collaboration between the Endocrine Society and MN Community Measurement (MNCM), initiated in 2021 to develop meaningful measures that focus on addressing obesity as a chronic multifactorial disease that requires the same systematic recognition, documentation, and management as other chronic health conditions. This collaboration gives endocrinologists and health systems a practical tool to ensure obesity is consistently recognized, documented, and treated with the same rigor as other chronic diseases, supporting better health outcomes for patients.

Consequences of Under-Documentation

Although obesity is widely recognized as a serious, costly disease associated with increased risk of type 2 diabetes, cardiovascular disease, cancer, and premature mortality, it remains underdiagnosed and undertreated in clinical practice. National data show that many adults who meet BMI criteria for obesity do not have a formal obesity diagnosis recorded in the EHR. This gap likely results from a combination of clinical and systemic barriers. On the clinical side, limited time, competing priorities, and apprehension or perceived stigma around discussing weight can discourage formal diagnosis. System level challenges such as EHR designs that do not facilitate documentation, or the absence of clear incentives and quality measures, may also make documentation inconsistent.

This under-documentation has several important consequences. Without a recorded diagnosis, patients miss opportunities for evidence-based interventions and are less likely to be evaluated for obesity-related complications. According to author and chair of the measure development group Amy Rothberg, MD, of the University of Michigan, a documented obesity diagnosis is key for early intervention. “We really want to intervene as early as obesity is recognized, before the onset of problems, or at least at the very early onset of other downstream health risks or consequences,” Rothberg emphasizes.

“The typical trajectory for the U.S. population is, on average, annual weight gain between 1.5 to 2.2 lbs. per year. If we can stop that change, we are already winning. We showed that those who had that diagnosis were more likely to receive care and lose weight.” – Amy Rothberg, MD, clinical professor, University of Michigan, Ann Arbor

At the population level, the lack of consistent documentation limits the ability of health systems to measure quality of obesity care, track outcomes, or identify disparities in recognition and treatment. Additionally, whereas failing to provide a diagnosis of obesity can reinforce bias, official acknowledgement of it as a chronic disease can reduce weight stigma.

A Multidisciplinary Analysis

To address this problem, a multidisciplinary team of 15 experts came together to create a standardized, EHR-based process measure that flags patients who meet BMI criteria for obesity but lack a corresponding diagnosis in their problem list. The panel represented the diverse fields of endocrinology, family medicine, internal medicine, clinical administration, data analysis, quality improvement, health plans, patient advocacy, and state government.  

The concept for this specific measure resulted from a landscape review showing that most existing obesity-related quality measures were either indirect or focused on screening and education, without addressing the fundamental question of whether obesity is being formally recognized and documented. As Rothberg notes, “If we are not aware of the disease, we simply cannot help patients manage it.”

After a 30-day public comment period, the measure was refined and pilot-tested across six large medical groups, including a federally qualified health center. In total, 124 clinics and 3,483 providers participated, covering 295,372 adult patients with BMI values consistent with obesity (BMI ≥ 30). The authors then assessed how many of these patients lacked a formal obesity diagnosis in their EHR problem list.

Providing Practical Care Benchmarks

Results of the pilot testing showed that rates of obesity diagnosis varied significantly among the medical groups (37.6% to 50.8%). This variability could reflect differences in clinical practice, patient demographics, and effectiveness of screening protocols. While low diagnosis rates may reflect a busy clinical practice (as Rothberg reports, it takes approximately six clicks to get from BMI to the problem list), it could also reflect the perception of stigmatization. Among those diagnosed with obesity, 35.4% were diagnosed as adult obesity class III, whereas 61.2% of adults with obesity class I lacked a formal diagnosis, indicating missed opportunities for early identification and early intervention with counseling and referrals for these patients.

The variation in diagnosis rates across and within medical centers presents opportunities for quality improvement that can be tracked with this process measure. Endocrinology practices often operate within health systems, accountable‐care organizations, and/or value‐based care models. For endocrinologists, the measure can provide a practical benchmark to track progress in obesity care.

A key finding of the pilot testing was that across the six centers, those with a documented obesity diagnosis lost on average 0.34 lbs. over the year, while those without the diagnosis gained on average 1.78 lbs. Though the weight difference in the follow-up cohort may seem modest, it matters. According to Rothberg, “The typical trajectory for the U.S. population is, on average, annual weight gain between 1.5 to 2.2 lbs. per year. If we can stop that change, we are already winning. We showed that those who had that diagnosis were more likely to receive care and lose weight.” In endocrine practice, official diagnosis may prompt more referrals, enrollment in lifestyle interventions, medication discussions, and long-term follow up.

The Pros and Cons of BMI

It is important to also consider the context and limitations of this measure. Critics point out that BMI remains an imperfect surrogate for adiposity and metabolic risk. A recent Lancet Commission report on the diagnostic criteria for obesity emphasized that clinical obesity definitions must go beyond BMI alone. The authors acknowledge the limitations of BMI as a diagnostic tool and the need for clinical judgement. However, BMI is correlated with body fat and disease risk and is simple and practical to implement in clinical practice.

“At the population level, the lack of consistent documentation limits the ability of health systems to measure quality of obesity care, track outcomes, or identify disparities in recognition and treatment. Additionally, whereas failing to provide a diagnosis of obesity can reinforce bias, official acknowledgement of it as a chronic disease can reduce weight stigma.”

In contrast, measures such as waist circumference or advanced imaging techniques like DEXA (dual-energy X-ray absorptiometry), while more precise, are less practical for routine use, and will take longer to implement effectively in current health settings particularly in the absence of any incentive or reimbursement. Beyond individual patient care, BMI data can also provide valuable insight into population level trends and health disparities, helping to inform public health strategies and guide interventions aimed at improving community health outcomes.

A First Step to Endocrinologist Reimbursement

For members of the Endocrine Society, this measure is particularly relevant. The Society has long emphasized that obesity should be managed like other chronic diseases requiring consistent recognition, documentation, and management. The finding that up to half of patients meeting BMI criteria had no documented obesity diagnosis underscores that this principle fails to translate into practice and presents an opportunity for quality improvement.

Formal recognition and inclusion of obesity on the problem list will not only initiate appropriate patient care but also serve as the first step toward endocrinologist reimbursement. This measure can serve as a foundation to strengthen the Society’s advocacy work around equitable access to care and physician reimbursement. Furthermore, the Endocrine Society’s clinical practice guidelines on pediatric obesity and pharmacological management, which are both currently undergoing updates, emphasize early recognition and intervention.

As the Endocrine Society continues its multi-year obesity strategy, tools like this process measure help practicing endocrinologists, primary care and family physicians, and other providers to achieve measurable, actionable improvement in obesity care. Recognizing obesity as a disease formally in the EHR problem list is not simply an administrative step. Rather, it is a formal validation that may reduce barriers to early intervention and evidence-based-care, improving long-term health outcomes for patients with obesity.

Maureen Corrigan, MA, is Director of Evidence-Based Clinical Practice at the Endocrine Society. Her work focuses on improving the quality, rigor, and trustworthiness of evidence-based clinical guidance, and translating research into improved endocrine care.